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Case Studies >
 Case
Study: Follow-up to a Hotline Complaint
Situation:
The Compliance Officer at a large healthcare system received an anonymous tip
complaining that two billers were changing ICD-9-CM diagnosis codes on Medicare
outpatient claims in order to bypass Medicare’s Local Medical Review Policy
(LMRP) edits. The tipster also informed the Compliance Officer that other
billers and staff were aware of this practice and one individual laughingly
suggested filing a “qui tam” suit. The Compliance Officer contacted QMCG
auditors and asked for an impartial investigation of the complaint.
QMCG Proposal:
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Determine the current process for assigning ICD-9-CM diagnosis codes.
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Determine the current process for handling claims, which fail LMRP edits.
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Determine if there is an “audit trail” available to check a diagnosis against
the physician’s documentation, the initial code assigned and the code at claim
release.
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Perform a focused audit on accounts, which have been identified as containing a
differing diagnosis anywhere in the billing system.
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Interview government billers and Health Information Management (HIM) staff
involved in diagnosis coding of outpatient services.
Conclusions:
Two individuals were altering the fourth and fifth digits of the ICD-9-CM
diagnosis codes on failed LMRP accounts; allowing the services to clear the
LMRP edits. These individuals were straightforward and admitted what they were
doing stating that changing the fourth and fifth digits did not change the
diagnosis by much. Releasing their claims kept their production up. Forwarding
the account to HIM for follow up “took too much time”.
Recommendations:
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Return any overpayments to Medicare.
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Re-educate billing staff to the importance of physician documentation
supporting the ICD-9-CM diagnosis code.
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Review the processes for obtaining the ICD-9-CM diagnosis for application to
the claim to see if the process could be streamlined.
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Monthly audits to monitor that ICD-9-CM diagnosis codes are supported by
physician documentation.
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Review policies and procedures related to coding practices.
Outcome:
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No further changes in diagnosis codes were found without physician
documentation.
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Billing staff stated they were appreciative that their concerns were taken
seriously.
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No qui tam suit has been filed.
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